Comment Regarding Prednisone Therapy for Recurrent Pregnancy Loss
Thursday, September 27, 2007
Kenneth F. Trofatter, Jr., MD, PhD
Anonymous said...
I was happy to read your thoughts on the immune/thrombophilic connections to recurrent pregnancy loss. I have had 3 miscarriages and 1 ectopic pregnancy causing emergency laproscopy and the loss of my right fallopian tube. We have been trying to conceive for 2 years...I recently saw a specialist in NYC... who diagnosed me with high antinuclear antibody (ANA) 1:320, speckled. I am now trying o conceive for the first time since the diagnosis and am nervous about taking prednisone. Have you noticed any severe side effects from this? I was also advised to take one baby aspirin (81 mg), 40 mg of Lovenox twice per day (I have homozygous MTHFR, homozygous PAI-1, heterozygous factor XIII V34L), Vitamin E, Metanx(a Folgard-like drug), progesterone(always had low progesterone around 7 after ovulation). I will probably take Clomid because in the past, it has helped raise my postovulatory progesterone levels...I have high CD 19 and CD 19+ cell, CD5+ on the NK (natural killer) cell assay...
Kenneth F. Trofatter, Jr., MD, PhD said...
To Anonymous Sept 20: You are a mess, Girl! Just kidding. I have seen much worse! It sounds like you are in pretty good hands. Did your doctors find any specific autoimmune antibodies known to be a problem in pregnancy, ie, anticardiolipin antibodies, lupus anticoagulant, anti-Ro(SS-A), or anti-La(SS-B)? Not that any of those would change your therapy at this point very much.
Your primary question seems to be related to the prednisone therapy - how much are you taking each day? Many years ago, prednisone was the foundation of our therapy for women suspected of having an immunologic basis for their recurrent pregnancy loss. Over the years, the literature has shown no great benefit of that, and potentially some harm, over anticoagulation therapy with unfractionated and low-molecular weight heparin (Lovenox). I usually reserve the prednisone for women with diagnosed autoimmune conditions such as systemic lupus erythematosus (SLE), who need to be treated for acute flares in their disease, and for women who decline heparin therapy because of the need for daily injections. Incidentally, despite the "high ANA," you do NOT meet the criteria for SLE (from what you have told me so far) and, indeed, many individuals who have modestly elevated ANA have no identifiable autoimmune or pregnancy-related problems whatsoever!
Prednisone therapy during pregnancy is associated with increased risk for gestational diabetes, infectious complications, premature rupture of membranes, and early delivery. It also increases your appetite (and weight) and fluid retention at high enough doses. If you absolutely don't need prednisone, try to get off of it by 20 weeks gestation. It probably isn't going to help much beyond first trimester in your case anyway.
Incidentally, I have also found that women in your situation with homozygous PAI-1 are insulin resistant and often benefit from therapy with glucophage (metformin) prior to and during their pregnancies. Anyway, thanks for reading and writing and I wish you the best of luck!
Dr T
Labels: recurrent pregnancy loss, thrombophilias
21 Comments:
At Tue Oct 16, 01:25:00 PM 2007,
Anonymous said…
I have a question on this drug I hope you can help please know if some one happens to take a hit off pot and then they end up haveing to take Prednisone will that keep it in the system longer because I know it stays with you for 3months or so so I hope you can help me. thanks heres my email wallsltr@yahoo.com
At Mon Oct 22, 04:53:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Oct 16: I doubt the prednisone would have much affect under those circumstnaces. But, if you are pregnant, be careful. Detection of any illicit drugs in some states is cause for putting your child in foster care after delivery. Good luck. Dr T
At Wed Nov 21, 06:55:00 AM 2007,
Anonymous said…
Hi DR. T,
I am anonymous(the mess ;>) I appreciate your response and using my story in your article. I had forgotten I had posted here and just found it again and thought wow that story is so similar to mine! Then I realized it was mine! I am still on the prednisone, 1 BA, 40 mg Lovenox 2X per day. Progestereone(oral and vaginal)Vitamin E and Metanx. I believe I had a chemical last month(Our first month trying again after antibiotic therapy) on 50 mg of Clomid-got a faint positive at 9 dpo then negatives and my period was 4 days late(I am like clockwork usually) So this month my Dr put me on 100 mg of Clomid and we tried very hard! I am 4 dpo so I'll let you know what happens. Thank you for getting out there that a "real" Dr believes there could be some truth to immunologic/thrombophilic causes of RPL.
Melissa
At Wed Nov 21, 06:59:00 AM 2007,
Anonymous said…
Hi,
It's Melissa again. I did not answer two of your questions.
I am on 20 mg of prednisone a day(10 mg in the AM and 10 in the PM)
I have been tested via the 2hr gluccose tolerance test and it appears my glucose levels are normal. Is metformin still indicated? Thanks
At Fri Nov 23, 05:28:00 PM 2007,
MariaIVIGG said…
I'll keep it short: At 31 I had 1 ectopic. 4 miscarriages. Diagnosed withPositive ANA1:160 fine speckle pattern on HEp-2.Did IVIGG sucess.Live birth. Took 7 month break sucess again with IVIGG. Took a 4 year break again IVIGG failure low beta. Pregnant again after 2 months failure again. DID IVF/PGD/IVIGG failure low beta. Stopped IVIGG.Then 2 more in vivo low beta failures. 5 pregnancies in 1 year...
Should i give prednisone a shot?
At Thu Nov 29, 04:59:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Maria: I'm not sure, but what you are doing now certainly isn't working. How old are you now? What is your primary infertility problem? Do you have any other medical problems that are being treated? What sort of 'workup' have you had for your miscarriages? Our REI folks believe that one of the primary reasons for IVF failures is endometriosis. Could that be true in your case? They love ovulation induction with Femara/hCG. Have you tried metformin and/or heparin/low molecular weight heparin? If not, I would go that route as comparable in yield to prednisone and with fewer side-effects. Dr T
At Fri Nov 30, 04:39:00 AM 2007,
MariaIVIGG said…
Hi. I just turned 39. I have no medical problems beside borderline ana. I conceive quickly but lose them very early. My problem is not conception but early miscarriage. IVIGG worked great between the miscarriages but does not seem to be doing anything. "They" say chrom.abnormality from poor quality eggs due to my age. I do not have endometriosis. A work up on miscarriages they only found "conception" material. They were to early for proper biopsy. In total I have had 11 miscarriages. Could the femara make me be ovulating "poor" quality eggs? Just reaching....
At Sun Feb 24, 04:35:00 PM 2008,
Anonymous said…
I'm about 4 months pregnant and just was prescribed prednisone but I heard it can cause serious birth defects such as cardiovascular defects, oral clefts, spina bifida, polydactyly, limb reduction defects and hypospadias. I'm taking 40 mg a day and am very concerned, the doctor did not tell me these side effects, the pharmacist did! I have had several miscarriages before and and one abortion at 16. I was wondering how serious are these side effects, I'm already in my 2nd trimester and the baby is in a serious stage of development.
At Wed Feb 27, 06:32:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Feb 24: Why were you placed on prednisone? Anyway, all those are birth defects that occur in the FIRST trimester. Prednisone is very safe from this point on in the pregnancy although, if you have to stay on a high dose for a long period of time, it does increase your risk for developing gestational diabetes and having premature rupture of membranes with early delivery. If you are on it for just a short period of time, it should not affect you ar the baby in any bad way. Dr T
At Tue Apr 29, 10:10:00 PM 2008,
Bibliophile said…
I too have a question regarding prednisone. I was placed on 40 mg per day for three weeks followed by taper off over the next 2 weeks. The treatment was for intractable hyperemesis. During that time I developed moon face, buffalo hump and gained 20 lbs. I have also developed gestational diabetes. My question is if GD is brought on by the prednisone, do I have more or less of a chance normal blood glucose functioning after delivery. Also, will the Cushings symtoms resolve over time or will my physical appearance remain altered.
Thank you in advance.
At Thu May 01, 06:34:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To bibliophile Apr 29: Prednisone tends to bring out 'type 2' diabetes (but also worsens the control of type 1 diabetes). Now that you are off the prednisone, how are your blood sugars doing? Prednisone does not usually cause you to become diabetic permanently, although by 'unnmasking' your tendency to deveop diabetes, it could lead to an earlier diagnosis of the condition or it might induce you to take preventive measures to decrease the chance of developing it over time. If you continue to have 'gestational diabetes' even off the prednisone, then you should be screened for it 6-8 weeks following your delivery, even if your blood sugars are all 'normal' in the immediate postpartum period. Good luck and let us know how things turn out! Dr T
At Thu Jul 24, 11:20:00 AM 2008,
Anonymous said…
Dr Trofatter,
I am a 30 year healthy woman & my problem is recurrent miscarriages. I had a miscarriage in April 07 at 7 weeks & I aborted naturally. I got pregnant again Nov but miscarried at 7 weeks in Dec 07. My doc. Did testing on the tissue & found it to be chromosomally abnormal at 69 XXY. (Triploid syndrome)
Dr. Scher in NYC who specializes in recurrent miscarriages did some testing (including a saline sonogram which was perfectly normal) & found:
1. High normal homocysteine
2. An elevated plasimongen Activator Inhibitor
3. One copy of C677T MTHFR mutation
4. Borderline (suspicious) IgM Phosphoethanolamine
5. Raised CD19 B cells, which is a marker for auto-antibody secretion such resulting (4) above.
6. Slight abnormality in my husband’s seminal fluid.
Dr. Scher put me on the following treatment:
1. Once Daily Primacare prenatal vitamin & thrice daily Folic Acid (Folgard OS).
2. On day 14 of cycle start baby Aspirin & on Day 18 40mg of Lovenox daily.
3. When pregnant use 200mg of vaginal progesterone in morning & 400mg at night.
I just found out that I am pregnant again :). My LMP was June 19 & the HCG level on 07/21 was 843 & on 8/23 was 1952.
On 07/21 my blood was sent to a lab in Chicago & I just found that the killer cells have risen to 13.5 from 4.5 (Done in Jan after 2nd miscarriage). Similarly the B cells have gone up to 17.9 from 15.5.
Although my HCG levels & progestrone levels are good my Doctor wants me to take PREDNISONE 5mg, 3 times daily. He also gave me article from Dec 2007 saying that taking Prednisone during first trimester leads to cleft lip/palate defects in children - 4 in 1000.
I am worried about the side effects & want advice if I should take Prednisone ? Please let me know if it is necessary ?
I am already taking 600mg vaginal progestrone, 40 mg lovenox, baby aspirin & folgard daily.
At Fri Jul 25, 07:13:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July 24: You are in very good hands. We used to use Prednisoone as primary therapy for recurrent miscarriages and the risks are small with regard to the baby. If Dr. Scher thinks you are a good candidate for this based on the laboratory studies, then consider it seriously. I have found that unless someone has a true autoimmunedisorder such as systemic lupus that need streatment, prednisone can often be stopped around 20 weeks, thereby, decreasing the risk to you of developing gestational diabetes from it or undergoing spontaneous premature rupture of membranes. Please let us know how things turn out. Dr T
At Tue Jul 29, 09:15:00 AM 2008,
Anonymous said…
Hello,
I cannot believe how incredibly generous you are. Thank you for spending your time replying to women like me.
I am currently pregnant - very early in the first trimester. However, it appears that I am miscarrying. This will be my third in the past several months. My bloodwork came back with antibody levels "through the roof" yet no thyroid disease. My endo thoguht it was idopathic antibody disorder and no treatment. She mentioned that she had "heard" that some obgyn's use pred.
My doctor is not familiar with the use of pred nor is she comfortable with it. Went to a high risk doctor who said the antibody levels could or could not play a part in the miscarriages and that I should try again with Lovenox. I haven't even had a chance to start the Lovenox yet.
Is there a NJ or NY doctor that you know of that is comfortable with pred therapy? Is it normal that they have not yet diagnosed the reason why I have antibodies?
Thank you,
At Wed Aug 06, 12:58:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July 29: sorry for the delay in responding but I have been on vacation. My first question is: What sort of "antibodies" do you have? Are these antithyroid, antiphospholipid, etc? I would need that information before I could even guess at a treatment regimen. I know there is a doctor in NYC who has a special interest in recurrent pregnancy loss - his name is Dr. Scher. I am sorry I can't be of more help right now, but I realy need more information from you! Take care. Dr T
At Thu Aug 07, 04:25:00 PM 2008,
BKFL said…
Thanks for ALL of your help..
I have had 6 Preg Losses in the past 3 years, one was a blighted OVum and the LAST two made it to 16 & then 12 weeks, (I was followed very closely every 2 wks for the 1st 8 wks,) I don't show signs of miscarriage, just no heartbeat at the check-up. I was taking 75mg synthroid, baby aspirin, progesterone,Primacare 1 & 40mg Lovenox. I am now taking 1000 mg Urso Forte and prednisone 10 mg daily, in addition to the vitamins, aspirin & synthroid. I have not been able to get pregnant for the past three mos, where as I have gotten pregnant in one or two mos every other time. I do have two boys ages 10 & 12 with my ex husband, healthy pregnancies & deliveries. I turned 40 two weeks ago. Anything you can offer in information would be GREATLY appreciated, as I am near the point of giving up. Thanks again, BKFL
At Sat Aug 09, 06:18:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To BKFL: Are you seeing a specialist in Reproductive Endocrinology. If not, I would strongly suggest you do ASAP. Assisted reproductive technologies (e.g., ovulation induction with IUI and IVF) may improve your chances because you are running out of time. Good luck! Dr T
At Mon Sep 08, 04:58:00 PM 2008,
Shs said…
Hello- thanks for your time- I have had four miscarraiges- three with heart beat that lasted between 5-7 weeks and the last one a blighted Ovum- for the last one I was on Prednisone, baby Apsirin,prgesterone, folgar- I have had all the test run and the only thing that shows up in MTHFR- now he wants to keep all above and add Heprin- what do you think?
At Tue Sep 23, 11:31:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To shs: The heparin is fine, but I do not think we yet have a cause for the losses. Did any of the pregnancies have chromsomal studies done on the products of conception? have you and your partner had chromsomal studies done? Have you had the inside of your uterus evalusted for possible abnormalities? If the next pregnancy does not work out, all of those things should be done and once the results are back, I might have some other suggestions for your management. Good luck on the next go-around! Dr T
At Wed Nov 12, 09:20:00 AM 2008,
Anonymous said…
Hi Dr T,
I am 35 years old and have had 6 rpl's in the last 2 years 9 months approx. After the 3rd we found out I have MTHFR (homozygous)and lupus anticoagulant. I started baby asprin, extra vitamins (b6,b12, Folic) and heparin with the 4th. That ended earlier than all my other pregnancies and was a natural miscarriage. It never really developed. 5 of my pregnancies all have had strong heartbeats and make it to about 8-9weeks. Longest was number 5 at 9wks 2 days. Unfortunately that pregnancy I was using contaminated heparin and it was a normal baby girl. We will never know why that one didn't work for sure. Anyhow so number 6 was my first try in my opinion with good drugs and it also failed. I had been switched to Lovenox 40 mgs 2xday for that one. My husband and I had done almost every test possible accept for the HLADQ test? The one to see if you genetically match and we are a 4.1 and a 4.2 Since my miscarriages were happening after 8 weeks and implantation isn't a problem we didn't really think that this could be a problem for us. So now I am on 5mg prednisone 2xday and after conception occurs I will go to 10mgs 2xday and of course all the other vitamins (b6,b12, extra folic and calcium)along with baby asprin. I get pregnant very quickly so I am hoping that continues since I just turned 35. My Dr. still thinks I have atleast a %50+ chance of pulling this off. Have you had any patients who have had the genetic issue be successful with having a baby? It is so hard to try and figure out the immune system. Hopefully someday there will be a solid method of treatment with high success rates for these problems. Being able to conceive is a miracle in itself but who would have ever thought it could be so haeart wrenching to try and carry to term a child. Thanks for listening. Just wanted to share my story and find out if you have seen anyone else like me. Thank you, Stephanie, WA.
At Thu Nov 27, 04:09:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Stephanie: Thanks for sharing. Perhaps someday we will have a pregnancy vaccine that will improve the chances for a normal maternal immune response to pregnancy and decrease the heartache of miscarriages in some women. It is something I have thought could be possible for more than 25 years and, yes, I have cared for many women in your situation. Best of luck and let us know when you hit a home run! Dr T
Post a Comment
<< Home